NCC222435_Contact Update Record (Legally Resp Change)_20220907

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 9/7/2022 8:55:28 AM (Contact Changes Submitted)

Certificate of NCC222435
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2022-2435
Original NOI No.* 96417
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
HPG NC Morehead City, LLC
Project Name Embassy at Morehead City
Address 3822 Galantis Drive, Morehead, NC
County Carteret
Latitude 34.7310
Longitude-76.7591
Date COC Issued * 07/07/2022
Prior Rescission Date This field will populate only if COC has already been rescinded.
Which Contacts Have Billing Only
Changed?* • Legally Responsible Individual Only
Site Contact Only
BOTH Legally Responsible Individual and Site Contact
Has Billing Contact Choose'Yes'to revise Billing Contact details.
Changed? U No
Yes
Billing Email [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 317-664-0266
NEW Billing [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Tom Smith
Individual (Previous)
First Name (New)* Thomas
Last Name (New) * Smith

NEW Legally Reflects any revisions above
Responsible Thomas Smith
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 802 East 86th Street, 0, Indianapolis, IN
Address (Previous) 46240
NEW Permittee Street Address
Mailing Address* 802 East 86th Street
Address Line 2
City
State / Province / Region
Indianapolis
IN
Postal / Zip Code
Country
46240
us
Permittee Street 802 East 86th Street, 0, Indianapolis, IN
Address (Previous) 46240
NEW Permittee Street Street Address
Address* 802 East 86th Street
Address Line 2
City
State / Province / Region
Indianapolis
IN
Postal / Zip Code
Country
46240
us
Change Requested Thomas C. Smith (Authorized Representative) via Modification Request submitted
by: * 8/30/2022.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation Previously listed as Tom Smith with different phone number. Updated information.
(Optional)
Date * 09/07/2022